The best surgery for early-stage lung cancer

Soon after Clarice Wong arrived at Mount Elizabeth Hospital in Singapore for a check-up, she was diagnosed with a non-small cell tumour on her lung with no evidence of metastases. Fortunately it had been found at a very early stage, she was informed by her thoracic surgeon at Mount Elizabeth Hospital in Singapore.

It was decided that a right lobectomy would be carried out using a minimally invasive surgical technique known as video-assisted thoracoscopic surgery, or VATS. The treatment would require no more than a two-night stay at the hospital, after which the 55-year-old non-smoker would likely be declared cancer-free and able to get on with her life.

“Having all gone to plan, Clarice will need no more treatment for the tumour, except for periodical surveillance over the next five years. She was able to return to work and normal activities just 10 days after the surgery,” said Dr Agasthian T, her specialist at Mount Elizabeth.

Lung cancer remains one of the most common cancers in Singapore. Though smoking continues to be the main risk factor for lung cancer worldwide, the disease affects a larger number of women in East Asia who have never smoked, compared to elsewhere in the world.

Whereas 5 percent of lung cancer patients in the West are women, this number spikes to 30 percent in Singapore. Like most cancers, it can be cured if detected early and surgically removed.

In its early stages, though, lung cancer can be asymptomatic. It can often be missed on standard chest x-rays and any symptoms will often resemble pneumonia or other conditions. The slow-growing nature of the tumour and a lack of awareness of lung cancer among perfectly healthy non-smoking females often leads to a delay in diagnosis and treatment.

However, the last decade has seen the wider use of low-dose spiral CT scanning as a screening tool, which has been proven to decrease the mortality rate of lung cancer-related deaths by 30 percent while administering much lower doses of radiation.

“After a diagnosis, VATS has been shown to have a 90 percent success rate in treating early cancers. It has been proven to have similar oncological cure rates to thoracotomy, a far more damaging procedure that involves breaking the ribs and spreading them to gain access to the chest cavity,” said Dr Agasthian.

“With VATS, there is no bone-breaking, which is the main cause of post-operative pain and less blood loss, leading to shorter admission and recovery times. And because of this, patients who need adjuvant chemotherapy can start their treatment earlier.”

The surgery is performed by a surgical team who watch the procedure on a high-resolution monitor. Central to it is a specially designed telescope that acts as their eyes in the lung. This is inserted into the chest cavity through a small incision and held by an assistant to provide the lighting, resolution and the magnification needed by the surgeon to perform the procedure with accuracy.

Images acquired at the front end of the telescope are transmitted without loss of image quality so they are sufficiently clear, sharp and sufficiently magnified.

The technique requires considerable hand-eye coordination by the surgeon and complex teamwork by his team. This explains why few medical centres offer the procedure and train their surgeons to perform it. Luckily for Clarice Wong, Mount Elizabeth has a team of accomplished surgeons who can perform VATS.

Dr Agasthian T pursued his specialisation in general thoracic surgery in America before returning to Singapore. Over the years he has trained most of the country’s thoracic surgeons and been involved in setting up thoracic surgery services at a number of hospitals there.